Transformation of Nursing Leadership In a Recovery Oriented System of Care

Unique Challenges that are Inherent to Leading Health Care Teams

One of the unique challenges that are inherent to leading health care teams is engaging interdisciplinary team members in the context of the difference in the roles and expectations of diverse professions. Often, conflict arises out of perceived ethical dilemmas in achieving patient care goals through different pathways. Members of any group may feel threatened by anyone who possesses new or progressive education or skills. Another consideration in difficult interdisciplinary relationships is the autonomous and independent nature of nursing practice (Grohar-Murray & Langan, 2011). Building connections and finding common ground amongst a variety of disciplines that approach patient care from assorted perspectives, can be a challenging task, but is one necessary for a nursing leader to master. 

There are many reasons that collaboration is difficult for healthcare professionals: Dissatisfaction amongst team members can result in decreased productivity and low morale. The first step in identifying the reasons for opposition to forming interdisciplinary coalitions is whether the resistance is to specific change or to the person or the force driving the development of the relationship (Ball, Weaver, & Kriel, 2004). One of the first considerations in exploring why progress is difficult is health care professionals’ inclination to rely on tradition (Zauszniewski, Suresky, Bekhet, & Kidd, 2007). Because the current transformational reformations in healthcare are such drastic changes, and represent the fear of the unknown and, consequently the fear of powerlessness (or at least decreased power), finding and utilizing “appropriate strategies to minimize or overcome resistance to change” is an ongoing, and at times, frustrating endeavor (Marquis & Huston, 2009, display 8.1). This challenge is intensified with the increasing capacities and use of technology.

The health issue considered in this paper is the lack of engagement by mental health services consumers of effective care delivery. In April 2002, “the President [of the United States] identified three obstacles preventing Americans with mental illnesses from getting the excellent care they deserve: 1) Stigmas that surrounds mental illness, 2) Unfair treatment limitations and financial requirements placed on mental health benefits in private insurance, and 3) The fragmented mental health service delivery system” (DHHS, 2003, p. 1). Initially and still primarily, the driving forces behind addressing these deficiencies are the mandates and guidelines put forth by government and regulatory agencies. “…When federal or state policies and funding priorities shift, local agencies often modify their programs and services in the same directions to maintain legitimacy and to secure the resources they need to survive” (Lauffer, 1984). “Mental health professionals and other health care providers are in a unique position to impact the lives of people with mental illnesses. Because of their scientific knowledge and special relationship with mental health consumers, providers have a singular opportunity through their attitudes and practices to promote self-esteem, self-efficacy, decision making about treatment, illness self-management practices, and recovery” (“Promote Acceptance,” 2008). 

Developing and Leading Teams in Health Care

Recognizing and effectively responding to the “fear of the unknown” is a significant role of a nursing leader in developing collaborative relationships. Effectively intervening is especially difficult in the context of the ongoing change throughout healthcare coupled with the demand for and scrutiny of evidenced-based practices. In the case of instituting evidence-based practices, the outlook for nursing will be profoundly impacted by the nurses’ ability to progress from convention to contemporary, concerted methods (Zauszniewski, Suresky, Bekhet, & Kidd, 2007). 

One of the first steps in communicating about change is to establish the necessity and the benefit of the change. In order to accurately convey the essentials of any change, the manager must use verbal and non-verbal language strategies that clearly and comprehensively speak to all stakeholders involved (Marquis & Huston, 2009). The “four facets of client readiness …[as] identified [by] Kitchie…: (1) physical readiness, which deals with ability, complexity of the task, environment, health status, and gender; (2) emotional readiness, which deals with the state of receptivity to learning; (3) experiential readiness, which reflects the learner’s past experiences with learning; and (4) knowledge readiness, which encompasses the learner’s knowledge and understanding” (Allendar, Rector, & Warner, 2010, p.321). 

In the framework of the transformation of mental health services, the primary restraining force for nursing leaders in implementing changes involved in transforming mental health services from the medical model focus on symptomatology to a recovery-oriented, person-centered paradigm has been and remains fear. This transformation renders the healthcare professional a consultant and requires the person in recovery (consumer) to help provide leadership not only in the beginning stages of his or her own care, but in the development of the milieu. This concept is in sharp contrast to the historical construct that employed the professional care provider as the authoritarian and required the person in recovery to receive, and not be a part of treatment prompting the effective use of collaboration. “Because the healthcare field is dynamic, necessitating constant and often substantial changes, the supervisor is confronted with the problem of how to introduce change” (Dunn, 2010, p. 477). 

In order to obtain support for teamwork from key formal and informal leaders in healthcare, the nursing leader must identify and assess the audience, carefully plan communication strategies and then effectively disperse the information required for the audience to come to a conclusion about the project (Polit & Beck, 2012). Different types of change and diverse perspectives of stakeholders necessitate consideration of a few change management strategies, one of which is the systems approach. This model is particularly applicable in the context of current technological changes because it incorporates mechanical and managerial factors involved in instituting an industrial change. Using this model, all internal and external issues are taken into consideration and planned for prior to and during the execution of the cooperative process, therefore the chaos and confusion that leads to resistance are resolved. 

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Health Care Literature and Research about Team-Building 

The leaders surrounding many healthcare projects are motivated in part by requirements for accreditation and financial viability structures, i.e., pay for performance criteria imposed by governmental and regulatory agencies. These regulations constitute  “[a]…group of classic change, power-coercive strategies,” (Marquis & Huston, 2009, p. 175). Fortunately, many of those governmental and industry agencies driving transformational changes also provide helpful supports and resources for implementing it (“Promote Acceptance,” 2008).

 “Cumming and McLennan’s (2005) argument that evidence alone is rarely sufficient to induce change…[normative-re-educative] strategies use group norms and peer pressure to socialize and influence people so that change will occur” (Marquis & Huston, 2009, p. 175). However, leaders must be cognizant that in some instances, workers may band together in withstanding team building efforts. Administrators must address this obstacle through improved inclusion of staff members in developing administrative policies and being representative on committees instrumental in furthering cohesiveness amongst team members. “Kerfoot (2006) says that ‘change that is sustained does not happen in organizations with top-down edicts’ (p.208)” (Marquis & Huston, 2009, p. 167).  According to the Philadelphia Department of Behavioral Health and Intellectual disAbility Services (2011), the inclusion of contributions from a comprehensive group of stakeholders is achieved by the development of a “change management team” (p. 25).

As far back as 1926, Mary Parker Follett wrote an essay entitled, “The Giving of Orders”; the essay proposed that managers possess power in collaboration with and not necessarily over employees. Follett’s philosophy is similar to transformational leadership. “Wolf, Boland, and Aukerman (1994) define transformational leadership as ‘an interactive relationship, based on trust, that positively impacts both the leader and the follower. The purposes of the leader and the follower become focused, creating unity, wholeness and collective purpose. The city requires this type of transformational leadership in Standard 6 of the Supportive Program Operations of the Philadelphia Department of Behavioral Health and Intellectual disAbilities’ Provider Network Standards and Content Summary. Specifically, the standard mandates “policies and procedures that promote recovery and resilience through: 1) Supervision, 2) Training, and 3) Leadership (Philadelphia Department of Behavioral Health and Intellectual disAbilities [PhilaDBH], 2011), p. 1). 

Another leadership model that is conducive to effective team building is servant leadership. The servant leadership philosophy lends itself to an inclusive work environment. The first two qualities of a servant leader are genuine comprehension and appreciation of an employee’s views by a tolerant and unprejudiced supervisor (Marquis & Huston, 2009).  Servant leadership was a concept developed in 1977 by Robert Greenleaf.  “Greenleaf argued that to be a great leader, one must be a servant first” (Marquis & Huston, 2009, p. 52). Servant leaders focus on the needs and development of their employees thereby improving the quality and quantity of organizational accomplished goals (versus primary focus on the organization). 

The defining qualities of servant leaders are:

• The ability to listen on a deep level and to truly understand
• The ability to keep an open mind and hear without judgment
• The ability to deal with ambiguity , paradoxes, and complex issues
• The belief that honestly sharing critical challenges with all parties and asking for their input is more important than personally providing solutions
• Being clear on goals and good at pointing the direction toward goal achievement without giving orders
• The ability to be a servant, helper, and teacher first and then a leader
• Always thinking before reacting 
• Choosing words carefully so as not to damage those being led
• The ability to use foresight and intuition
• Seeing things whole and sensing relationships and connections

(Marquis & Huston, 2009, p. 53).

The foundation of servant leadership aligns with the philosophy and practice of Philadelphia Department of Behavioral Health and Intellectual disAbilities’ Transformation Guidelines’ 

Goal C: Develop Inclusive, Collaborative Service Teams and Processes with  the objective of using the skills and experience of staff and volunteers strategically. It suggests the following potential strategies: 1) Use the knowledge of stakeholders to develop a community resource file, and 2) use the experiences of staff, participants, peers, families and allies in the community to continually update and expand knowledge of potential resources and partners in the community (Philadelphia Department of Behavioral Health and Intellectual disAbility Services [Phila. DBH], 2011, p. 100). 

Regardless of which model is used, all-encompassing communication must be used in order to ensure the continued understanding of and enthusiasm for change processes (Shute et al., 2012). For example, in their effort to engage more nurses in the process to enable all members of the nursing profession to efficiently utilize electronic health records (EHRs), The Technology Informatics Guiding Education Reform (TIGER) Initiative formed two collaborative teams whose function it was to gather nurses from a variety of specialties for inclusive discussions about developing standards and practices that would further along the initiative’s purpose (Technology Informatics Guiding Education Reform [TIGER], 2009). 

In the mental health field, the inclusiveness of all service consumers (including clients, providers and families) has been increasingly mandated in all areas of developing service paradigms and systems (Davidson, Tondora, Lawless, O’Connell, & Rowe, 2009). When it comes to rapidly progressing technological changes, researchers found that nurses were afraid of their role being reduced and their identity altered. The leaders involved in this change needed to recognize these factors prior to starting to initiate technological changes so that the nurses’ resistance is lessened or non-existent (Ball et al., 2004, p. 82). 

Whether in an administrative or front-line role, leading and working with a team is essential in making positive changes that result in improved patient outcomes. Professional organizations and practice guidelines support these collaborative efforts (Garner, 2011). Over the last twenty years, a new model called integrative healthcare clinics has developed in Canada under the premise that interprofessional teamwork is a best practice in delivering progressive, comprehensive care (Gaboury, Lapierre, Boon, & Moher, 2011). In examining the specific interventions and practices of operative nursing leadership, researchers have found that when nursing leadership functions in interdisciplinary, interdependent collaboration while planning and delivering strengths-based, person-centered care, transformational care goals can be realized.  “To be effective in reconceptualized roles and to be seen and accepted as leaders, nurses must see policy as something they can shape and develop rather than something that happens to them, whether at the local organizational level or the national level” (National Research Council, 2011, Chapter 5). 

The current financial situation in this nation and more particularly, in the healthcare arena, requires the nurse to increase his or her stewardship skills and to more efficiently and effectively provide quality patient care in an environment that focuses on positive clinical outcomes while lacking economic and professional resources. The resulting difficulties of these circumstances is illustrated in “an American Nurses Association national survey that 69 percent of nursing responding reported that they confront ethical issues daily to weekly and that 49 percent of those issues were related to ‘cost-containment issues that jeopardize patient welfare’’” (Roy, 2000, p. 123). Furthermore, current fiscal restraints require the nurse to remain diligent in regard to his or her ethical responsibilities to gauge the “influence of the environment on ethical obligations” and to take “responsibility for the healthcare environment” (American Nurses Association [ANA], 2001). In achieving improved clinical outcomes, it is especially imperative that the nurse actively participate in professional development with scrupulous evidence-based practice.

The scarcity of resources is further exacerbated by a population that is increasing in number and in age. “Between the years 1960 and 1995 persons in the United States aged sixty-five and older increased from 16.9 million to 33.9 million. The number of people seventy-five years and older is expected to reach 6.1 percent of the population in the 2000 census and increase to 7.9 percent five years after” (Roy, 2000, p. 121). The aging population presents medical problems that are increased in complication and in amount. Again, this requires the nurse to maintain a current and well-rounded knowledge base and skill set. Of special consideration is attention to preventative efforts in addition to curative measures. “Debate continues about how to move from a health care system focused on cure to one that can promote health for the elderly with disabling conditions” (Roy, 2000, p. 121). 

Nurses are a necessary force for positive change with respect to quality and safety initiatives. Staff nurses are the front line contact between administration and the patients in the execution of new initiatives. If staff nurses don’t understand or don’t have the motivation or resources to effectively implement quality and safety improvement initiatives, the initiatives will never reach the patient. Nurses should seek out and embrace change that addresses (and hopefully improves) any practice that is ineffective or damaging. 

Background

In the presenting summary of  its 2011 report, The Future of Nursing: Leading Change, Advancing Health, the Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine states:

This report offers recommendations that collectively serve as a blueprint to (1) ensure that nurses can practice to the full extent of their education and training, (2) improve nursing education, (3) provide opportunities for nurses to assume leadership positions and to serve as full partners in health care redesign and improvement efforts, and (4) improve data collection for workforce planning and policy making (National Research Council, 2011, p. 1).

All of these goals are directly impacted by the decision making processes of leaders and members of the nursing profession. The report stresses that nursing team leaders must make greater use of group decision making approaches. This involvement is important at all levels and in all arenas. The report, as part of its key messages, maintains that nurses must serve in partnership with communities, consumers and with other professionals, including physicians. In addition, the report states, “Nurses also should serve actively on advisory committees, commissions, and boards where policy decisions are made to advance health systems to improve patient care” (National Research Council, 2011, p. 33). 

Leaders must have the skill to effectively employ techniques such as testing, consulting and joining in their efforts to not only effectively engage the group, but also successfully reach a decision on the best course of action.

 Two of the major characteristics defining group effectiveness discovered by these studies are: (1) consideration, the extent to which the leader is likely to have a group relationship characterized by mutual trust, respect for subordinates’ ideas, and consideration of their feelings; and (2) initiating structure, the extent to which a leader is likely to define and structure the roles of subordinates toward goal attainment. The most effective leaders scored high on both of these measures (Grohar-Murray & Langan, 2011, p. 29).

Decision making skills can be learned and are necessary for any leader to effectively solve problems. The first step in the decision making process is to identify exactly what the circumstances of the situation or problem are. In order for the problem to be properly identified, the manager must canvas the environment and interview all the stakeholders so that the picture is genuine and comprehensive (Dunn, 2010). Following that, the facts that have been defined must be gathered and analyzed. The manager must not only consider the information provided (some of which will be subjective) but also the incorporeal data that will potentially affect the decision outcome. Some of the things to consider include, how the decision will be perceived, if the morale of the people involved would change,  if quality will be affected and if so, how. As with any decision, ethical and moral implications must be considered (Dunn, 2010).

Subsequent to this analysis, a careful review of all possible alternate scenarios must take place. In order to make sure that all alternatives are considered, in addition to brainstorming amongst involved employees, an internet search may be conducted.  From all the alternatives identified, an evaluation of them will occur and the best one is chosen. If the decision will potentially or actually result in change, the leader must consider that those involved will probably be very reluctant when the change comes if there was no collaborative process involved. Again, the team leader must be cognizant of, receptive to and invested in the premise that meaningful change is more likely to happen when it’s been investigated, when those involved are a part of planning and when everyone can clearly and completely recognize the goal, as in this way, trust is established. “The biggest factor of resistance is mistrust” (Marquis & Huston, 2009, p.177). Once this process has been carefully pursued, the selected option is then implemented, appraised, and on an ongoing basis, re-evaluated (Dunn, 2010). 

Lewin’s model of the development of change is one model often demonstrated as the decision to proceed is implemented. Lewin identifies circumstances that ought to be accounted for in decision making. Circumstances that promote and sustain change are named driving forces, while those conditions that hinder and are obstacles to change are restraining forces. Two common restraining forces are inopportune timing and ineffective power on the part of the person leading the change. Also, fear of those people who may be affected by the change is a significant roadblock. In all of these circumstances, choosing an internal change agent who is familiar with the operations and culture  of the setting  in which the change will occur will help ensure appropriate timing, power and earned confidence of subordinates. 

Lewin’s model summarizes the change process in three steps: (a) unfreezing, (b) movement, and (c) refreezing. At the crux of the unfreezing period, the information gathered from the staff during inclusive discussions is presented to bring forth any further questions, comments or concerns that the staff has in order that there be a shared belief that the change is necessary. Only with this belief can the progression overlap and move into the movement period.  “Before any change can occur, people must believe the change is needed, as a result of a comprehensive decision process, can it occur” (Marquis & Huston, 2009). 

It is during the movement stage that more significant roadblocks can occur. Most of these will involve conflicts with scheduling and personalities (Dunn, 2010). It is during this time that the change agent must intervene in these complex situations and, using effective planning and communication skills, coordinate logistics of implementation as well as the collaboration of the involved employees in order to successfully achieve comprehensible and well-established goals (Marquis & Huston, 2009). The final stage in the Lewin’s model is re-freezing. During this stage, stabilization and integration occurs (Marquis & Huston, 2009). This acceptance of the change into a state of normalcy will result from the manager’s guidance and skills in providing oversight to the implementation plan and supervision of its goals and process (Reinertsen, Bisognano, & Pugh, 2008). 

Another model for making decisions while solving problems is the IDEALS model. The steps of this process are: 

• “Identify the problem
• Define the context
• Enumerate the choices
• Analyze options
• List reasons explicitly 
• Self correct” (Marquis & Huston, 2009).

Because of the IDEALS mnemonic, this model can be referred to quickly and easily. Like Lewin’s model, involving participants affected by the ultimate decision in examining the context of an issue will prompt thorough investigation of contributing factors and potential consequences. 

One more model that provides structure for the decision making process is the Diffusion of Innovation Model. The first construct of the Diffusion of Innovation Model is newness. “The newness of an innovation can be with regard to knowledge, persuasion, or the decision to adopt” (Sharma & Romas, 2012, p. 230). This is new to the practices and philosophy of behavioral health service delivery as a whole because prior to recent transformation, assessment and treatment focused on symptoms and diagnosis – not the person as a whole, not the person in context of a citizen and not the person a collaborator in his or her own care.

The next construct of the model is the innovation-decision process. This is a “five- step process: 1. Gaining knowledge about innovation 2. Being persuaded about innovation 3. Deciding whether to adopt or reject the innovation 4. Implementing the innovation (putting it to use) 5. Confirming step: either reversing the decision or adopting the innovation” (Sharma & Romas, 2012, p. 233). All of these efforts will result in having “channeled leadership attention to system-level improvement” (Reinertsen, Bisognano, & Pugh, 2008, p. 14).  Finally, as part of decision making, it is essential that nurses be aware of and utilize the resources available in order to ensure the use of best practices. These resources include legislation, codes of ethics, industry regulations, and professional organizations. There was legislation passed in 1972 that created professional standards review organizations (PSROs). These organizations examine the necessity of treatment and ensure quality of care and manage payment dependent on performance improvement data and outcomes. 

Conflict Management

Although it may be the most positively productive, staff nurses don’t favor collaboration as a conflict management technique. By encouraging collaboration, the nursing leader not only promotes identification of issues that require resolution, but also allows for teamwork development. To approach conflict via this method, the nursing leader would begin by reframing conflict from being perceived as a negative process into an affirmative one. This contextual change would be achieved by using words such as, “… exciting, creative, helpful, courageous, stimulating, growth producing, strengthening, and clarifying” (Grohar-Murray & Langan, 2011, p. 93). Effective collaboration requires team members who are strong individuals, with various areas of expertise and who can make a commitment to team goals (Allendar, Rector, & Warner, 2010, p. 21).  The failure of the team leader to effectively build cohesiveness and establish norms amongst the team members around the intervention could result in a shift in focus from the team effort (intervention) to inter-team conflict. Also, “compromise can be an effective strategy because it is a win-win proposition for both parties…” (Pearson, Nelson, Titsworth, & Harter, 2011, p. 208). Use of these methods limits the difficult person from having much to question, much less argue about. I have found that the majority of conflicts- from marital spats to psychiatric crises- can be de-escalated with effective communication skills. 

As a profession, nursing must consider the ethics, laws, guidelines and regulations presented by industry and governmental agencies that relate to professional relationships and conflict therein. Also, health care professionals must be cognizant of the changing awareness and expectations of the public we serve. In addition to the transformational, transparency based guidelines being employed in current healthcare regulatory philosophies, Roy (2000) points out that the community at large has more access to information as a result of the increased communication technology. Because transformational, recovery-oriented care values the collaborative relationship between practitioners and consumers, collaboration as a system for conflict management and resolution is exceptionally applicable. Civil, collaborative interprofessional teamwork “…may also reduce the amount of workplace bullying and disruptive behavior, which remains a problem in the healthcare field (Joint Commission, 2008; Olender-Russo, 2009; Rosenstein and O’Daniel, 2008)” (National Research Council, 2011, p. 223). A list of conflict-provoking, yet commonly-used workplace phrases includes:

• Our place is different
• That’s not my job
• Let’s get back to reality
• Everybody does it this way
• It’s a gimmick
• Too hard to administer
• They don’t pay me enough
• Do your job, don’t do anything else and you won’t get into trouble 
• That’s not how we do it here 
• You’ll make the rest of us look bad

As part of their specialty skill set, psychiatric nurses learn about and develop vast experience cultivating positive communication climates. Many experiences of mental health professionals involve communication with difficult people. These involvements often cumulate use of a positive and assertive communication style. “The assertive communication style is demonstrated by communication that says directly and clearly what is on one’s mind. It is also demonstrated by listening to what others say. The leader uses objective words, uses “I” messages, and makes honest statements about the leader’s ideas and feelings. Part of an assertive style is the use of direct eye contact, spontaneous verbal expressions, and appropriate gestures and facial expressions while speaking in a well- modulated voice” (Grohar-Murray & Langan, 2011, p. 56). 

Emotional Intelligence (EI)

Modern leadership theorists purport that emotional intelligence (EI) is just as, if not more, important than any other ability or competence of nursing leaders. “Rao (2006) concurs, arguing that while IQ and technical skills are increasingly being recognized as critical to successful leadership and management, it is EI that is the ‘sine qua non’ of leadership” (Marquis & Huston, 2009, p. 55). Emotional intelligence is the capacity to recognize, adapt to and proficiently amalgamate connections with those around us in a meaningful and productive manner. As it relates to conflict management, Morrison (2008) purports, “the art of relationship management is necessary when handling other people’s emotions. When conflict is approached with high levels of EI, it creates an opportunity for learning effective interpersonal skills” (Morrison, 2008, p. 1).

A significant factor for consideration when evaluating EI is that the potential for meaningful empowerment of their workforce by emotionally intelligent nursing leaders is dependent on the leaders’ span of control; if the span of control is so excessive as to disable purposeful interaction with staff members, the benefits of emotional intelligence are limited (Lucas, Laschinger, & Wong, 2008). Because nursing leaders must be able to engage, support, motivate and educate frontline providers, their success relies on their ability to connect with staff at an emotional level. Existing research shows that an emotionally intelligent leader can greatly impact not only his or her job satisfaction, but also the job satisfaction of the employees supervised. Furthermore, emotional intelligence can be a learned skill and when employed effectively can positively impact recruiting and retention (Feather, 2009). 

Specific Ways to Implement this in the Community

 In implementing transformational care, nursing leaders must appreciate the community nurse’s autonomous role as a collaborator as well as the interdependence the community nurse has with other members of the community including other professionals, e.g., doctors, social workers, etc… and other social agencies, e.g., support groups, political action groups, etc… A concise term for the role of the community nurse is that of a case manager- in a variety of settings and at many levels. “Case management is a systematic process by which a nurse assesses clients’ needs, plans for and coordinates services, refers to other appropriate providers, and monitors and evaluates progress to ensure that clients’ multiple service needs are met in a cost- effective manner…[When referring to case management as it pertains to communities, case management] involves overseeing and ensuring that a group’s or population’s health- related needs are met, particularly for those who are at high risk of illness or injury” (Allendar et al., 2010, p. 51). 

When considering community interventions, special consideration must be given to the ethics involved, and the possible positive as well as negative outcomes possible. One such focus is the ethical principle of autonomy (self-determination), which allows for one to exercise freedom of choice in decision making in regard to his or her life.  This principle is not only an ethical standard, but also is one of the philosophical foundations underlying strengths-based, transformation mental health care. A person’s autonomy must be carefully considered in cases involving people with altered or impaired cognitive functioning.  “When a person cannot fully comprehend the options, the consequences of actions related to the options, and the true costs and benefits, he may not have adequate capacity for making health care decisions”  (Allendar et al., 2010, p. 81). Because of these circumstances, there are times where the nurse must invoke the paternalism principle and take responsibility to report the abuse to the authorities. “…Paternalism is justified only to prevent a person from coming to harm” (Marquis & Huston, 2009, p. 75). 

The community assessment allows the nurse to evaluate possible community places and resources.  In the initial stages of the community assessment, the nurse involves current health care providers, educators, politicians, clergy and long-standing residents. During a project to embed nursing students in a West Virginia rural community, “The ARONPCNC Project Director / preceptor in West Virginia arranged for a windshield survey of the area with a driver who had grown up in the community. This took the better part of a day, and this person served as a key informant and access point for them to speak with other residents” (Morgan & Reel, 2003, p. 34). In order to systematically conduct the survey, the “community –as-partner” model was used during this project. “Areas of assessment data were recreation, physical environment, education, safety and transportation, politics and government, health and social services, communication, and economic” (Morgan & Reel, 2003, p. 34).

“The configuration of the [health care] team will be determined by those individuals who are able to assist in the stated goal of the group. Teams are currently viewed as an extremely efficient and effective method for complex decision making” (Allendar, Rector, & Warner, 2010, p. 66). The implementation of a community intervention plan could positively affect the health care team by strengthening their shared bond. The stronger bond would be a result of collective empowerment, effective collaboration, improved knowledge and the accomplishment of the resulting positive evidence based results in the community as a result of the intervention.  

The work of any community-based initiative is to strive to develop and empower the community as a whole, and from the health care professional’s perspective, concurrently to optimize the health of the community and bring about improved health chances (Beattie 1991, Tones & Tilford 1994). …There is the assumption that knowledge, skills and health gain acquired by individuals in group-work will somehow permeate through to influence larger groups, with an eventual collective community health response or empowerment (Duignan & Casswell 1989) (Billings, 2000).  

In order to minimize the negative impact of an intervention, the community health nurse can meaningfully contribute to the team not only through his or her professional input, but also through her personal characteristics. This is demonstrated in the following quote by a community health nurse, “My job assignment, location, and team members changed frequently. Flexibility, comfort with ambiguity, a sense of humor, a deeper reliance upon my faith, patience when results were not forthcoming, trust in others, and the ability to cross multiple cultures with some degree of ease were all skills that I developed over time. Most important to being successful at my job was to maintain the attitude of a “learner,” not a “solver of problems’ ‘ or” the person “with all the answers’ ‘ (Allendar et al., 2010, p. 101). 

From the perspective of the recovery-oriented care transition, a comprehensive plan to transform the community’s coping skills and purposeful utilization of mental health services was developed and began with the complete, functional and meaningful implementation of the “Welcoming Process” portion of the Transformation Initiative. The Transformation Initiative is the process by which our facility is meeting “The Federal Action Agenda on Mental Health Transformation” expectations. The vision and the tagline for the Substance Abuse and Mental Health Services Administration (SAMHSA) of this transformation process is “A life in the community for everyone” (Substance Abuse and Mental Health Services Administration [SAMHSA], n.d).  The plan to accomplish this re-evaluation involves inciting change amongst the healthcare workers who interact with and engage consumers at the outset.  “This project embodies [a concept] discussed in the book From Client to Citizen, ‘with millions of people involved in reaching out to strangers for help and to help, the self help movement reweaves our social fabric, establishing connectedness based on mutual responsibility and mutual respect. Health public life depends on this connectedness (Lappe’, F.M., & Dubois, P. M., (1994)” (Attwood [Drass], 2001, p. 126).

Key Stakeholders and Community Alliances

One of the major stakeholders in this process is the community. The community in this case is vitally important to consider as the physical location of the behavioral health facility will directly impact the surrounding area. The community consists not only of the residents of the neighborhood, businesses, community groups and law enforcement, but also the consumers seeking recovery. Along with the consumers, stakeholders include their supports, including churches, families, and collaborative social agencies. 

In considering the effect on the community as a result of better engagement of Behavioral Health Services, a neighborhood assessment must be done. Conducting a community assessment allows service providers to identify the needs, barriers, strengths and resources in the community. The facility that serves the targeted community is located in lower North Central Philadelphia, an area geographically close to downtown Philadelphia, but very distant in terms of health care access, economic status and social and cultural makeup.  North Philadelphia is an area which suffers from virtually all of the burdens of economic deprivation and NPHS remains among the few institutional pillars which have remained committed to the community (NPHS, 2011).  

The immediate area of the facility is bordered by neighborhoods which are being revitalized; however, the specific community (neighborhood) from which our consumers come has been socioeconomically deprived and culturally diverse since the great depression. The ethnicities that are predominant in this neighborhood are African-American and Latino. “In past decades, North Philadelphia was hit hard by economic decline. The majority of North Philadelphia’s residents are African Americans and Hispanic Americans. Despite its wealth of history, schools, cultural sites, parkland, architecture, and other holdovers from more prosperous times, unfettered poverty has earned North Philadelphia a reputation as a slum” (“North Philadelphia,” 2011).

Further complicating the ethical and advocacy landscapes is the values and belief system in the community. ‘My neighborhood was an excellent community, everybody knew everybody, we were a close-knit community, we always helped each other out’ –Ms. Gwen Moses, longtime resident of North Philadelphia (“Community Displacement,” n.d.). Because of the perceived lack of justice, attention and compassion from officials and politicians with whom they interact, the culture of the neighborhood is that of distrust of outsiders and is best described in the context of the “Stop Snitchin’” crisis. “From T-shirts to web sites, the “Stop Snitchin’” campaign has grown despite efforts by police and community leaders to encourage residents to come forward with information regarding violent crimes in their area. For those who believe that this Code of Silence is a recent phenomenon fueled by hip hop culture, Samuel George is quick to point out a deep-seated historical connection” (“Stop Snitchin’,” 2008). 

The ability of treatment facilities and social agencies to credibly engage or intervene with this community is significantly inhibited because of the culture of residential restrictiveness in dealing with health as well as with crime. This is important to note, as support from all members of the community is vital to successful educational interventions. “I want to present you with a simple proposition: that all-out efforts to deal with healthcare providers, business and insurance companies, government and the media and to make treatment better and cheaper will fail if we don’t change our behavior as a community. Specifically, I believe that we’ve got to set aside our personal prejudices, adjust to reality and be willing to compromise for the greater good (National Alliance for the mentally Ill, 2000)” (Attwood [Drass], 2001, p. 9).

“A White House drug policy report (2000) states that the community as a whole is impacted by drug use and addiction because drug activity invites crime and criminal activity into a neighborhood. Residents often feel helpless and fearful when confronted with drug use and associated criminal activity, dissuading them from civic involvement or problem solving efforts. However, a poll shows that ‘drug war’ efforts should be directed toward prevention and treatment rather than law enforcement” (Attwood [Drass], 2001, p. 7).  It is in this perspective that the welcoming process, including outreach and engagement, can make the greatest impact by progressing toward the goal of the transformation as it relates to community relations and public health in the neighborhood in being more person-centered and recovery-oriented. “Encouraging individuals to uphold their own well-being promotes the avoidance of acute care due to preventable illness and supports the soundness of the community” (Attwood [Drass], 2001, p. 162).

Another important aspect of the culture of the community as a whole is that because there has been momentous revitalization of some of the areas surrounding the neighborhood, the newer residents are frequently in conflict with the existing residents and with the institutions that serve them. This dissatisfaction with the local health care providers due to umbrage toward the clientele they serve has resulted in the some residents’ protest to local politicians, the police, local business owners and to the informal neighborhood leaders to increase punitive, restrictive and/ or legal measures in regard to all persons in recovery and residents who support them. Efforts to educate the community about the disease of addiction, or more importantly, the possibility and process of recovery, are inhibited by many of neighbors’ aggravation and misperceptions regarding various mental illnesses, including the disease of addiction. Introducing the benefits of treatment for not only the consumers receiving it, but also for their friends and families in the community will better engage the neighborhood audience presently and in the future. “When people have a better understanding of the facts, they will be less likely to stigmatize mental illnesses and more likely to seek help for mental health problems. The actions of reducing stigma, increasing awareness, and encouraging treatment will create a positive cycle that leads to a healthier population” (Department of Health and Human Services: New Freedom Commission on Mental Health.  [DHHS], 2003, p. 10). 

Research indicates that the team building process not only benefits the care delivery team, but also on the leader who is leading the change. The shared relationship facilitates the manager’s appraisal of personal and professional capabilities, organizational intent and role expectations while empowering the team to communicate more meaningfully and to more clearly identify and accomplish their responsibilities. Engaging employees who work closely with the merchandise or process to come together to achieve a specific result often results in feelings of validation by the employees. 

The team members are gratified to be recognized for their potential ability to succeed (Dunn, 2010).  “Several factors have been identified as critical to a high functioning clinical team. They include; leadership, systems support for the clinic team, having a patient focus, staff education and training, having ready access to information and embedded process improvement efforts” (O’Toole, Cabral, Blumen, & Blake, 2011, p. 10). Current culture expects that managers will have the ability to provide staff members with the tools, resources and accountability for their own positive performance in working toward good patient outcomes and purposeful accomplishment of organizational goals. “…It is essential that the manager has an understanding of group dynamics, including the sequence that each group must go through before work can be accomplished” (Marquis & Huston, 2009, p. 456). 

Administrators must now acquire the education and skills in order to accommodate this paradigm shift from the traditional expectancy of the manager being entirely responsible for the conduct of employees (Grohar-Murray & Langan, 2011). “The leader must guide staff and others through the process of disrupting their current practice patterns, encourage them to let go of current realities, introduce new patterns, encourage them to adopt new standards and stabilize the equilibrium as quickly and painlessly as possible” (Stichler, 2011, p. 166-67). In developing and leading high-performance teams, the leader must establish clear goals and the generalized guidelines and programs by which staff is expected to reach them. By methodically creating these predictable constructs, leaders enable staff members to make familiar, “programmed decisions” based on regimented procedures Furthermore, in unexpected circumstances, when “non-programmed decisions” must be made, the supervisor must possess critical thinking and decision making skills (Dunn, 2010). 

Regardless of the type of decisions to be made or the objectives to be realized, skilled supervision in combination with significant enablement of the team is essential. When the team building process is designed and executed effectively, worthwhile results are produced.  For example, “Christian Hospital in St. Louis achieved a 50 percent reduction in turnaround time for transcribed reports after implementing a process improvement team. The team was given the freedom to address the situation and used that freedom to identify the cause of the problems and initiate solutions (Peckron and Herbst 2006)” (Dunn, 2010, p. 468). 

Another important leadership aspect of team building is coordination. Coordination is strategic alignment of each team member in working toward and accomplishing a common goal (Dunn, 2010). This is especially important as nursing leaders are expected to not only lead the nursing team, but also to partner with the leaders of a variety of interdisciplinary team members (National Research Council, 2011). It is imperative that team leaders understand the vast differences in communication and interactions that occur between individuals from that which happens amongst team members. One team building organizational methodology, Theory Z, has found success through its concentration on long-term service at one facility, unhurried and deliberate positional advancement, shared decision making, communal accountability and relaxed regulation. This theory presumes that members of staff strive to construct meaningful relationships with their coworkers. Although this has been a predominantly Japanese model, it is interesting to note that it was introduced to them by a pair of Americans following World War II (Dunn, 2010).  Consideration of this theory caused this author to reflect on its prospective appropriateness for use in union environments where loyalty to fellow union members and long tenures are the custom. 

“Tuckman and Jensen (1977) labeled [the team building] stages forming, storming, norming and performing” (Marquis & Huston, 2009, p. 456). Forming describes the stage of the team building process when people gather together to form a task-oriented group. Participants not only learn about each other, but also establish their identities within the context of team functioning (Dunn, 2010). Once the team has formed, the team progresses to the second stage called storming. Storming is a phase where thoughts, suggestions and ideas are competitively presented for consideration. “The…situation of competing objectives among different team members, inefficient or intransigent care systems, limited infrastructure support and no objective feedback fosters a culture resistant to change and quality improvement” (O’Toole, Cabral, Blumen, & Blake, 2011). Because the team must be cohesive and focused in working toward collective organizational goals, it is a managerial task for the leader to provide meaningful supervision during the storming stage.

Moving forward from the storming stage, team members begin to identify and inaugurate policies and practices for accomplishing the goals. During this stage, called the norming stage, the importance of administrative direction is highlighted. In communicating directives, managers must be cognizant of the audience receiving the information, “…they should take into account the training they have had, the content of the directive, the underlying managerial attitude, and the time available” (Dunn, 2010, p. 466). Supervisory oversight also is important during this time because this can be the most uncomfortable for those members of the team who are not well versed in or at ease with confrontation and conflict. Because multiple options are being established and standardized by many people with different personalities, the potential for interpersonal struggle is substantial during the norming stage. “While team building is useful for organizations, it must be periodically evaluated. Teams present evaluation challenges to managers. Individual evaluations rendered in a team environment can be troublesome because they tend to undermine teamwork and cooperation by stressing individual competitiveness” (Fallon Jr. & McConnell, 2007, p. 239) 

The fourth developmental stage for building a productive group is performing. During the performing stage, the focus and the efforts of the team participants move from cooperative contemplation back to task accomplishment. During this time, roles develop flexibility and create functionality (Marquis & Huston, 2009). It is also during this time that the team leader must reinforce the concerted efforts of the team. “…Nurses must help and mentor each other in their roles as expert clinicians and patient advocates. No one can build the capabilities of an exceptional and effective nurse like another exceptional and effective nurse” (National Research Council, 2011, p. 234). 

Some theorists have proposed a final stage that occurs at the time the team disperses. This final stage has been named the closure, termination or adjourning stage (Marquis & Huston, 2009; Fletcher, 2008). It’s important for team leaders to know that, “If the team arrests at a particular stage of development, it can become less productive and may fail to mature. Teams tend to mature more rapidly when:

• The task is important
• The individuals are highly committed
• Individual and team objectives are aligned (Fletcher, 2008).

Upon its conclusion, periodic evaluation of the team’s results is necessary. When indicated, adjustments should be made. “Accurate information from evaluation reports permits the correction of neglect and inconsistencies” (Grohar-Murray & Langan, 2011, p. 266). The effective use of productive teams led by skilled facilitators can be one of the most industrious and beneficial interventions a nursing leader can initiate. 

 

Proposed action plan

The planned intervention involved leading change amongst the healthcare workers who interact with and engage consumers of mental health services from the community that surrounds a two hospital health system.  The next strategy is the normative ––re-educative strategy. This strategy uses peer pressure and the task group process to push the change process forward.  Use of normative-re-educative strategies can be disadvantageous, as the workers may band together in withstanding the change. Leaders should address meeting this obstacle through the inclusion of staff members in developing administrative policies and being representative on committees instrumental in furthering the transformation.

Although the Welcoming Process segment of transformation initiative and the evidence-based interventions practiced within exude the basic ethical principles of inclusion of all consumers, their families and their supports, of freedom of choice and of the use evidence-based practices by care-givers, there are concerns that may affect the ability to persuade or be persuaded about this project. The first concern is that in promoting self-determination of each consumer, the population with which an individual consumer is receiving treatment may be adversely affected. Compounding the problem is that in an inpatient or residential treatment setting, this dilemma becomes a significant difficulty for the staff and, therefore, one of the grounds for resistance to implementation efforts. To deal with this dilemma, “the Recovery Model does not suggest that consumer choice should be encouraged at the detriment of other consumers or program rules…Program rules that are set for the benefit of all should not have exceptions made in the name of the Recovery Model.  However, consumers who do not like the rules of a particular program or residential facility should have the right to find a program that will better meet their needs” (National Association of Social Workers, 2006).

Another concern that has slowed the rate of adoption is the ability of the consumers to more readily make self-determined choices; in some cases, these choices may be detrimental. Depending on the consumer’s motivation, ability to judge and/ or cognitive abilities, the conclusions they reach could range anywhere from not the most healthy choice to one that is harmful, i.e., refusal of clinical interventions in a time of crisis. When facing a consumer’s choice that is not the best choice but that lacks harm, “we have a responsibility to “support the dignity of risk and the right to fail” (attributed to Pat Deegan, 1996, as cited at U.S. Department of Health and Human Services, 2005a)” (National Association of Social Workers, 2006). 

To address these situations, it is incumbent upon clinicians to provide the support and education necessary for the consumer to make the most positive and informed choice. “If their goal does not seem rational to us, then we need to help them understand the implications and realistic possibilities, but they need and have a right to make the decisions” (National Association of Social Workers, 2006). Should the consumer’s choice(s) present the risk for harm, the ethical mandates of professional nurses, and of all professionals, demand interventions that will prevent such harm (“Code of ethics for nurses with interpretive statements”, 2001). 

As far as the effectiveness and implementation processes, the “planned change and desired outcomes [were] very clearly outlined” (Marquis & Huston, 2009, p. 169) at the federal, state and institutional levels. More effective collaborations and communications achieved in part through the implementation of this process have started to yield results as observed through the clarity and meaningful distribution of information to the treatment delivery staff, consumers, citizens, politicians, administrators and community leaders involved in changing the community’s conflict filled culture regarding behavioral health treatment. Initial signs of success have also been noted quantitatively through a decrease in injuries for both the staff and consumers, unexpected discharges, i.e, against medical advice and an increase in the number of community members presenting to the facility.

Goals

The basic anticipated result of this phase of the overall transformation project is to augment the current practice of merely completing the Biopsychosocial Assessment in a very basic and less-than-significant way.  A more meaningful and thorough assessment and engagement of the consumer will be achieved by ensuring that staff is more attentive to and detailed in interviewing the consumer and that each staff member is more in tuned to hearing a cue or prompt to ask follow up questions. A goal of the leaders in this process will be to educate staff members about and to appoint them to ascertain not just what the facts are, but to answer the questions about: who, why, how, and what does the acquired information mean for the client? Also, the interviewers must determine and document what the acquired information means for clinicians providing treatment. 

 

Key Factors in Measuring Success

Objective information as gathered and observed by the project coordinator has been and the criterion used to evaluate the implementation plan and is being assessed in evaluating the outcomes of the intervention.  “Accurate information from evaluation reports permits the correction of neglect and inconsistencies” (Grohar-Murray & Langan, 2011, p. 266).  The goals of this intervention within the context of the entire transformation movement as defined by the Philadelphia Department of Behavioral Health (2011) (Philadelphia Department of Behavioral Health and Intellectual disAbility Services [Phila. DBH], 2011, p. 29) are:

1. Provide integrated services
2. Create an atmosphere that promotes strength, recovery and resilience
3. Develop inclusive, collaborative service teams and processes
4. Provide services, training and supervision that promote recovery and resilience
5. Provide individualized services to identify and address barriers to wellness
6. Achieve successful [service delivery/ consumer] outcomes through empirically informed approaches
7. Promote recovery and resilience through evaluation and quality-improvement processes

As indicated as part of the initial evaluation of the plan, one of the most important indications of positive results by the leader is the enhanced ability and attitude of the front-line staff.  “The empowerment of staff is a hallmark of transformational leadership. To empower means to enable, develop or allow. Empowerment…can be defined as decentralization of power. Empowerment occurs when leaders communicate their vision, employees are given the opportunity to make the most of their talents, and learning, creativity, and exploration are encouraged. Empowerment plants seeds of leadership, collegiality, self respect, and professionalism”. Administrators must be mindful of whether improvements are being negatively impacted by personnel and process changes or as a result of financial constraints. 

Managers should continue to further observe progress through existing monitoring tools such as nursing performance improvement initiatives related to the standards around transformation. One of the most significant evaluative indicators of this intervention will be verbal and financial feedback from the Philadelphia Department of Behavioral Health’s managed care department, Community Behavioral Health (CBH). CBH has set forth specific criteria for consumer assessment by the care providers. The length of stay and level of care are determined by the information gathered and then relayed to the reviewers at CBH. Another consideration in this example is the dissatisfaction of the consumer on being authorized for a lesser level of care. In this one example, there are two criteria that may not be useful in evaluating the results of the intervention. 

Objective information as gathered and observed by the project coordinator should be included in the criteria used to evaluate whether or not a nursing leader has developed a good intervention plan.  In this way, obstacles and difficulties will be identified and addressed. “Accurate information from evaluation reports permits the correction of neglect and inconsistencies” (Grohar-Murray & Langan, 2011, p. 266). Many models for the evaluation of interventions exist. One popular model is Deming’s “Plan-Act-Do-Check” model; another comprehensive model is the RE-AIM model.  

“The RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework, which provides a practical means of evaluating health interventions, has primarily been used in studies focused on changing individual behaviors” (King, Glasgow, & Leeman-Castillo, 2010). Other models include: 1) Donabedian Model, 2) Quality Health Outcomes Model, and 3) American Nurses Association Model. “Models of client caregiving are based on structure, process, and outcome; ideally, they provide structure to guide nurses through the nursing process to reach desired client outcomes” (Allendar, Rector, & Warner, 2010, p. 344). 

“The evaluation criteria should be compared to a variety of issues, such as: ( 1) the acceptability of action for a particular organization or setting, ( 2) the psychological- social acceptance of the selected action, ( 3) the effect— direct and indirect— on the quality of nursing care, ( 4) the possible growth for the group implementing the plan, and, finally, ( 5) the solution’s ability to maintain order” (Grohar-Murray & Langan, 2011, p. 38). In addition, during planning and after the intervention, the project coordinator and/ or participants should evaluate “results in relation to expenditures” (Allendar et al., 2010, p. 218). 

 Anecdotal information, satisfaction feedback and personal opinions in regard to the outcomes of the project should not be used as criteria or cannot be used independently of the objective and/ or quantitative criteria listed above. “The accuracy of using [satisfaction] outcomes as a primary measure of quality care is limited, because some clients have unsatisfactory outcomes despite receiving good care” (Allendar et al., 2010, p. 341). Also, the outcomes should be evaluated by the structure and criteria described above and not necessarily by what the health care team expected the outcomes to be. 

Ultimately, the results of the implementation of the interventions will be in how well we follow the Mission Statement of the Transformation Initiative:

Under the leadership of our clients, our mission is to deliver unique care that meets the needs of each person. In partnership with our clients and their families, we will set goals and commit to treating everyone with dignity and respect. Our environment will be unconditionally supportive, warm, and inviting. We will work as a team to provide positive and creative programming that helps clients reach their goals. Reflecting a diverse community, we offer care that is nourishing, culturally based, and spiritually sensitive. Ultimately, our hope is that each client will realize their vision of a meaningful life in society (NPHS, 2008).

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